Browns Valley Health Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Browns Valley, Minnesota.
- Location
- 114 Jefferson Street South, Browns Valley, Minnesota 56219
- CMS Provider Number
- 245564
- Inspections on file
- 19
- Latest survey
- April 21, 2026
- Citations (last 12 mo.)
- 7 (1 serious)
Citation history
Health deficiencies cited at Browns Valley Health Center during CMS and state inspections, most recent first.
A cognitively impaired resident, dependent on staff for all ADLs and functioning at a child-like level, was verbally and physically abused during toileting care when a NA used foul, aggressive language and struck the resident’s bare buttocks after the resident became combative. A second NA in the room and a TMA outside the closed door witnessed or overheard the yelling, swearing, and the smack, and both promptly reported the incident to the charge LPN and in writing. The LPN did not read the written complaint, did not immediately assess the resident, did not notify the on-call nurse, and allowed the NA accused of abuse to continue working the remainder of the shift with the resident and other vulnerable residents. In the following days, staff documented that the resident became withdrawn, tearful, refused meals and favorite drinks, and showed increased behavioral disturbances, representing serious psychosocial harm linked to the abusive incident.
A resident with dementia, depression, and a psychotic disorder, who was dependent on staff for ADLs and incontinent care, was allegedly subjected to verbal and physical abuse by a NA during toileting, including foul language, an aggressive tone, and an open-hand smack to the buttocks. A TMA overheard yelling and abusive language and, along with another NA who witnessed the smack, reported the incident to an LPN and completed a complaint form. The LPN did not read the complaint, did not further question staff, and did not immediately assess the resident or notify the on-call nurse. The facility’s incident report to the State Agency was not submitted until well after the required two-hour reporting window, while the alleged abuser continued working with residents.
A resident with dementia, depression, psychotic disorder, and moderate cognitive impairment, dependent on staff for all cares, was allegedly subjected to verbal and physical abuse by a NA during evening cares, including aggressive, profane language and an open-hand smack to the bare buttock while the resident cried and whimpered. Two staff members reported the incident to a charge LPN that evening, but the LPN did not immediately notify the on-call nurse, did not ensure the resident’s immediate safety, and did not document or complete a timely skin or behavior assessment. The alleged abuser continued working with residents until the next morning, and when the investigation was later initiated, it was limited to interviews of a small number of verbally responsive residents, without documented skin checks or behavior chart reviews for non-verbal residents and without interviewing all relevant night staff, contrary to the facility’s maltreatment reporting policy.
The facility failed to ensure proper food safety and hygiene practices, affecting all 28 residents. The dietary manager was observed handling clean dishes without a hair restraint, and multiple food items in the kitchen and resident refrigerators were improperly labeled or expired. This was against facility policies requiring hair restraints and proper food labeling to prevent foodborne illness.
A facility failed to disinfect a multi-use glucometer between uses for two residents requiring blood glucose monitoring. The RN and LPN involved did not follow the manufacturer's disinfection guidelines, risking the spread of infections. The facility's infection preventionist and DON confirmed the improper disinfection practices, which contradicted both the manufacturer's instructions and the facility's policy.
A resident with diabetes received insulin without the pen being primed, contrary to manufacturer's instructions. An RN administered 8 units of Humalog insulin without priming the pen, believing it was unnecessary. Interviews with the consultant pharmacist and DON highlighted the importance of priming to ensure correct dosage. The facility's policy and manufacturer's guidelines were not followed, resulting in a significant medication error.
The facility failed to submit accurate staffing data to CMS for a quarter, as discrepancies were found between the PBJ report and actual staffing records. Licensed nursing staff, including RNs and LPNs, were present on the dates in question, but incorrect coding of LPNs and TMAs led to inaccuracies. The administrator confirmed the issue, acknowledging the PBJ report's inaccuracy.
The facility failed to ensure proper wheelchair positioning for a cognitively impaired resident, whose feet were observed dangling without support, and did not comprehensively assess or implement interventions for another resident with edema. Staff interviews revealed a lack of recent therapy evaluations and inconsistencies in edema assessments, with no physician's order for compression stockings despite the resident's preference. The facility's policies for adaptive equipment and compression stockings were not followed, contributing to these deficiencies.
Failure to Protect Cognitively Impaired Resident From Physical and Verbal Abuse and Delayed Response to Allegation
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired resident from physical and verbal abuse by a nurse aide and to respond appropriately once the allegation was reported. On the evening in question, two nurse aides were providing toileting and peri-care to the resident, who had non-Alzheimer’s dementia, depression, a psychotic disorder, and moderately impaired cognition with long- and short-term memory loss. The resident functioned at an estimated developmental level of an 8-year-old, had unclear speech, responded only to simple direct communication, and was dependent on staff for all ADLs including toileting and hygiene. During care, the resident became combative, yelling and swinging her arms, and one aide (NA‑B) responded by raising her voice, using foul and aggressive language, and striking the resident on the bare buttocks while stating that if the resident wanted to act like a child, she would be treated like one. A trained medication assistant (TMA‑A) standing outside the closed door heard NA‑B yelling at the resident to hurry up and grab the “fucking bar” and to walk to bed, and later learned from the other aide (NA‑A) that NA‑B had swatted the resident’s buttocks. NA‑A, who was in the room, described NA‑B’s tone as loud, aggressive, and intimidating, and reported that the resident was grunting and appeared nervous. NA‑A stated that after the resident yelled and grunted during brief placement, NA‑B told the resident that if she wanted to act like a child she would be treated like one, then smacked her on the right buttock with an open hand, skin-to-skin, producing a loud smack. NA‑A reported feeling very uncomfortable and believed the conduct was verbal and physical abuse. After leaving the room, NA‑A immediately told TMA‑A what had happened and, within about five minutes, located the charge nurse (LPN‑A) and reported the incident. NA‑A completed an Employee Concern form describing the incident and placed it in the DON’s box. TMA‑A also informed LPN‑A during the evening medication count that she had heard raised voices, swearing, and the resident crying, and that NA‑B had smacked the resident’s buttocks. Despite these reports, LPN‑A did not read the written complaint, did not conduct an immediate assessment of the resident, did not contact the on‑call nurse, and allowed NA‑B to continue working the remainder of the 12‑hour shift, caring for the resident and other residents without additional supervision. In the hours and days following the incident, the resident demonstrated changes in behavior and mood that were documented by staff. The next morning, staff noted the resident was tearful, withdrawn, and refusing food and drink, including favorite beverages, and she cried while in her wheelchair in a common area. Nursing notes and behavior monitoring entries over the subsequent days documented increased yelling, hitting, scratching, cursing, and physical aggression during care, as well as episodes of sadness, tearfulness, withdrawal, and isolation. Staff familiar with the resident, including RN‑A and NA‑E, reported that this withdrawn, tearful, and non‑eating behavior was not typical for her and that she usually did not cry without a reason. Although a full body assessment was later documented as showing no bruising and no verbalized pain, the facility’s own records and interviews describe that the resident became more tearful, had decreased appetite, and increased crying following the incident, and that she appeared different than normal—quiet, exhausted, withdrawn, and refusing to participate in usual activities and intake. These events, combined with the failure of the charge nurse to act on the initial reports and remove the alleged perpetrator from resident care, led to the cited deficiency for failure to protect the resident from abuse.
Removal Plan
- Reported abuse to the State Agency (SA).
- Investigated allegations of physical and verbal abuse and implemented resident protection.
- Re-educated staff on abuse and neglect, reporting, abuse prevention, resident rights, dementia, and vulnerable adults.
- Verified education through interviews and training records.
Failure to Timely Report Alleged Verbal and Physical Abuse to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of abuse to the State Agency within the required two-hour timeframe after the allegation was made. On 2/21/26 in the evening, a trained medication assistant (TMA-A) stood outside a resident’s closed door preparing medications and heard the resident and a nursing assistant (NA-B) yelling. TMA-A heard NA-B say in a rude and aggressive tone, “hurry up and grab the fucking bar you know how to fucking walk so walk to the bed.” After NA-A and NA-B exited the room, NA-A told TMA-A that NA-B had swatted the resident on the butt. TMA-A considered this verbal and physical abuse and reported what she heard and what NA-A told her to the charge nurse (LPN-A) during a medication count shortly after 7:00 p.m., assuming LPN-A would notify the on-call nurse. NA-A reported that while assisting the resident in the bathroom, the resident became combative and yelled after NA-B told her to stand up. NA-B responded, “if you want to act like a child then you will be treated like one,” and with an open hand smacked the resident on the right buttock, skin-to-skin, producing a loud smack. NA-B then grabbed the resident’s walker and directed her to walk to bed. NA-A described NA-B’s tone as loud, aggressive, and accompanied by foul language, and stated the resident was whining, whimpering, and making grunting sounds as if nervous. After leaving the room, NA-A and TMA-A reported the incident to LPN-A, who provided NA-A with a complaint form. NA-A completed the form and placed it in the DON’s box, believing the incident would be handled and reported. The resident involved had non-Alzheimer’s dementia, depression, and a psychotic disorder, with unclear speech, limited verbal and non-verbal skills, disorganized thinking, and moderately impaired cognition with long- and short-term memory loss. She was dependent on staff for personal and toileting hygiene, transfers, bathing, and lower body dressing, and was always incontinent of bladder and frequently incontinent of bowel. Despite the information provided by TMA-A and NA-A, LPN-A did not read the written complaint, did not further question staff about the incident, and did not immediately assess the resident or contact the on-call nurse. The facility’s incident report was not submitted to the State Agency until 2/22/26 at 4:22 p.m., well beyond the policy requirement to report suspected maltreatment, including abuse, to the State Agency immediately but no later than two hours after the allegation is made. During this time, NA-B continued to work the remainder of the shift and care for residents.
Failure to Protect Resident and Conduct Thorough Abuse Investigation
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient protections and assessment following an allegation of staff-to-resident abuse, and failure to conduct a thorough investigation. A resident with non-Alzheimer’s dementia, depression, a psychotic disorder, moderately impaired cognition, disorganized thinking, unclear speech, and dependence on staff for all cares and transfers was allegedly subjected to verbal and physical abuse by a nursing assistant during evening cares. According to staff interviews, the nursing assistant spoke loudly, aggressively, and with profanity, telling the resident to hurry up and grab the bar and to walk to the bed, and stated that if the resident wanted to act like a child, she would be treated like a child. Staff reported that the nursing assistant used an open hand to smack the resident’s bare buttock, which sounded like a loud smack, while the resident was whining, whimpering, and making grunting sounds. The incident was reported by two staff members to the charge nurse on the evening of the alleged abuse. A trained medication assistant reported hearing the loud, aggressive, and profane language from outside the resident’s closed door and, after speaking with another nursing assistant who had been in the room, learned of the smack to the resident’s buttock. That nursing assistant also directly reported to the charge nurse that the staff member had been verbally aggressive and had smacked the resident’s right buttock. The charge nurse responded verbally but did not immediately contact the on-call nurse as required by facility policy, did not ensure the resident’s immediate safety, and did not initiate the required assessment and protective measures at that time. The resident’s medical record contained no documentation of a skin assessment or behavior assessment on the date of the incident, and there was no evidence of a documented skin check following the initial report of the allegation or the following day. The facility’s investigation process was also deficient. The alleged perpetrating staff member continued to work with residents for the remainder of the shift and into the next morning after the incident, and the allegation was not brought to the attention of supervisory nursing staff until the following day. When the investigation was initiated, the clinical coordinator interviewed a limited number of residents who were verbally responsive and in their rooms, totaling 11, and did not verify that skin checks or behavior chart reviews were completed for residents who could not be interviewed. Night staff who had worked with the accused nursing assistant, including the nursing assistant on the night shift with her, were not interviewed. The DON acknowledged that the charge nurse did not follow the facility’s maltreatment reporting guidelines, which required immediate reporting, suspension of the involved staff, and initiation of an investigation including resident and staff interviews, observations, and medical record review. The DON also acknowledged that resident skin monitoring and behavior chart review were not completed as expected, and that the facility’s policy was not followed by the charge nurse regarding communication of the incident and immediate protective actions.
Deficient Food Safety and Hygiene Practices
Penalty
Summary
The facility failed to ensure proper food safety and hygiene practices in the kitchen, which had the potential to affect all 28 residents receiving food and beverages. During an observation, the dietary manager was seen handling clean dishes without wearing a hair restraint, despite having hair approximately 1/4 inch in length. This was against the facility's policy that required all dietary staff to wear hair restraints to prevent hair from contacting exposed food or clean dishes. The dietary manager was unaware of the need for a hair restraint due to the short length of his hair. Additionally, the facility did not adhere to proper food labeling and storage practices. Several food items in the kitchen refrigerator, freezer, and resident refrigerator were found without proper labeling, dating, or were past their expiration dates. Items such as slices of ham, hamburger patties, apple pie, salsa, mayonnaise, and various other food products were either not dated or had expired, which was contrary to the facility's policy on perishable food management. The dietician confirmed that all food items should have been dated when opened and discarded after their shelf life or expiration date to prevent foodborne illness.
Failure to Disinfect Glucometer Between Uses
Penalty
Summary
The facility failed to properly disinfect a multi-use glucometer after use for two residents who required blood glucose monitoring. This deficiency was observed during the care of two residents, both of whom had cognitive impairments and required assistance with activities of daily living. The registered nurse (RN) and licensed practical nurse (LPN) involved in the incidents did not follow the manufacturer's guidelines for disinfecting the glucometer between uses, which is necessary to prevent the spread of blood-borne infections. The RN did not disinfect the glucometer after using it on one resident, while the LPN incorrectly used an alcohol wipe, believing it was sufficient for disinfection. The facility's infection preventionist and director of nursing confirmed that the glucometer was used for multiple residents and acknowledged that the use of an alcohol wipe was not appropriate for disinfection. The manufacturer's guidelines specified the use of an EPA-registered disinfectant or a bleach solution for proper disinfection. The facility's policy also required decontamination of reusable equipment between residents according to the manufacturer's instructions. This oversight in infection control practices had the potential to affect all residents requiring blood glucose monitoring.
Failure to Prime Insulin Pen Leads to Medication Error
Penalty
Summary
The facility failed to ensure professional standards of practice were followed during the administration of insulin to a resident with severe cognitive impairment and diabetes mellitus. The resident's care plan required staff to administer diabetic medications as ordered. However, during an observation, a registered nurse (RN) prepared and administered 8 units of Humalog insulin to the resident without priming the insulin pen as per the manufacturer's instructions. The RN did not prime the pen, which involves wasting 2 units of insulin to remove air bubbles, because she believed it was unnecessary since she had administered insulin to the resident earlier in the day. Interviews with the consultant pharmacist and the director of nursing confirmed the importance of priming the insulin pen to ensure the correct dosage is administered. The manufacturer's package insert and the facility's medication administration policy both emphasize the need to prime the pen before each injection to avoid administering too much or too little insulin. The failure to prime the pen was a deviation from these guidelines, leading to a significant medication error in the administration of insulin to the resident.
Inaccurate Staffing Data Submission to CMS
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) for the first quarter, as required by CMS specifications. This deficiency was identified during a review of the Payroll Based Journal (PBJ) Report, which highlighted several dates where there was a failure to have licensed nurse coverage 24 hours per day. The review of staffing schedules and time cards from October 1, 2023, through December 31, 2023, showed that licensed nursing staff, including registered nurses (RNs) and licensed practical nurses (LPNs), were present and worked on the dates in question. However, discrepancies were found between the PBJ report and the facility's staffing records. During an interview, the facility administrator confirmed the findings and acknowledged that the PBJ report was inaccurate. The administrator explained that the LPN staff and trained medication aides (TMAs) were not coded correctly in the PBJ system, which led to the inaccuracies. The facility's policy on PBJ, dated April 1, 2019, mandates the electronic submission of staffing information based on payroll data to ensure compliance with regulatory requirements. The Employment System Department (ESD) is responsible for reviewing all PBJ data for accuracy before submission to CMS, but this process was not followed correctly, resulting in the deficiency.
Deficiencies in Wheelchair Positioning and Edema Management
Penalty
Summary
The facility failed to ensure proper wheelchair positioning for a resident with severe cognitive impairment and multiple diagnoses, including dementia, arthritis, and low back pain. The resident was observed multiple times with her feet dangling from the wheelchair, indicating a lack of proper support and positioning. Interviews with staff revealed that the resident had not been assessed for wheelchair positioning, and there was no recent therapy evaluation to address this issue. The facility's policy required referrals to occupational or physical therapy for wheelchair assessments, but this was not followed. Additionally, the facility did not comprehensively assess and implement interventions for a resident with edema, who had diagnoses including heart failure, hypertension, chronic kidney disease, and diabetes mellitus. The resident's care plan included monitoring for edema, but there were inconsistencies in the assessment records, with some entries left blank. The resident expressed a preference for wearing compression stockings, but staff reported difficulties in applying them, and there was no physician's order for their use. The facility's policy required continuous assessment and monitoring of lower extremities when using compression stockings, which was not adequately documented or communicated to the primary care physician. Interviews with the director of nursing confirmed that the facility's usual process for wheelchair assessments was not followed, and the resident's feet should not have been dangling. The director also acknowledged the lack of a physician's order for compression stockings and the need for proper measurement and fitting. The facility's failure to adhere to its policies and procedures for adaptive equipment and compression stockings contributed to the deficiencies observed in the care of these residents.
Latest citations in Minnesota
A resident with intact cognition and multiple diagnoses, including AFib, HF, stroke, anxiety, and depression, was permitted to self-administer nebulizer treatments after staff setup without an IDT self-administration assessment. The EMR lacked documentation of the resident’s competency and safety to manage the nebulizer, including understanding the medication, following directions, operating the equipment, recognizing side effects, and storing the medication and equipment. Staff and the DON confirmed the assessment had not been completed before the self-administration order was implemented.
Failure to Assess and Monitor Antipsychotic Use: A resident with severe cognitive impairment, dementia, anxiety, and mood disorder received Risperidone for agitation and paranoia, but the EMR did not show an AIMS assessment on admission or timely target behavior monitoring. The RN case manager and DON confirmed that baseline AIMS and ongoing behavior monitoring should have been in place when the antipsychotic was started, but the resident’s record lacked measurable target behaviors and documentation of medication effectiveness.
Incomplete Care Plans for Anticoagulant Therapy and Cardiac-Related Needs: The facility failed to include key diagnoses, devices, and medication-related risks in care plans for two residents. One resident’s plan did not address Eliquis use, cardiac conditions, pacemaker presence, or condom catheter care, and another resident’s plan did not address Eliquis therapy or related bleeding-risk monitoring. The DON and RN case manager confirmed these items should have been care planned.
Failure to provide scheduled bathing and grooming assistance: Two residents with intact cognition and ADL dependence did not receive bathing as documented on a weekly schedule, and one resident also had unaddressed facial hair and greasy, unkempt hair. Records did not show consistent weekly baths, additional refusals, or reasons for missed care, and staff interviews confirmed residents were expected to receive at least weekly bathing unless they refused and that facial hair should be shaved when noticed.
A resident with intact cognition and multiple diagnoses, including BPH and stroke, had a physician order for a condom catheter at bedtime, but the EMR lacked orders or instructions for cleaning, disinfecting, monitoring, or changing the drainage bag. During observation, the bag was seen hanging in the bathroom, and an LPN, RN case manager, and DON all confirmed the absence of documented guidance for the catheter drainage bag care.
Failure to preserve dignity occurred when staff placed a brief on a cognitively intact resident who was continent of bowel and bladder. The resident stated the brief made him feel like a baby, and a NA confirmed she applied it even though he was not incontinent; RN and DON both verified the resident was continent and that briefs should not be placed on continent residents.
Failure to provide restorative ambulation and respond to a decline in mobility: A resident with dementia, weakness, chronic pain, and limited physical mobility was care planned for daily ambulation with a FWW and staff assist of 1, but the rehab record repeatedly showed ambulation as not applicable and staff interviews confirmed the task was often not done. The resident stated she could no longer walk, staff reported she had not walked for weeks and now required a sit-to-stand lift with assist of 2 for transfers, and the chart lacked an ADL decline assessment or revision of the ambulation care plan.
A resident with mild cognitive impairment, hemiplegia, hemiparesis, and limited ROM had restorative orders for PROM, stretching, and hand splints, but staff did not consistently offer or complete the interventions. Documentation showed the splints were sometimes marked not applicable instead of refused, and leg stretches were completed only a few times with no explanation for missed care. Staff interviews confirmed the restorative tasks often were not done, and the DON stated the resident’s restorative program needed to be updated.
Dirty can opener and contaminated dry storage bins: The DCS observed four labeled dry-goods bins with dirty rims, dry matter on the bin walls, and a scoop left inside a flour bin with flour on it. The attached can opener also had dry red matter on the blade, and the cook said it had been used that morning to open cream of corn for lunch. The DCS verified the findings and stated the can opener should be washed after each use and the dry bins and scoops should be kept clean.
Dignified Medication Administration Not Maintained: A resident with severe dementia, hallucinations, anxiety, PTSD, and delusional disorder was observed during med pass in the dining room. An RN attempted to administer meds by pouring them from a plastic cup into the resident’s mouth, continued despite the resident pulling away and moving her head, and then raised her voice and questioned why the resident would not take the meds after one pill was spit out and thrown on the floor. The resident stated the nurse was not being nice, and the RN left with the refused meds.
Missing Self-Administration Assessment for Nebulizer Use
Penalty
Summary
The facility failed to ensure an interdisciplinary team (IDT) assessment was completed before allowing a resident to self-administer nebulizer treatments. The resident had intact cognition and required assistance with ADLs, and diagnoses included atrial fibrillation, heart failure, BPH, stroke, malnutrition, anxiety disorder, and depression. Physician orders showed Ipratropium-Albuterol nebulizer treatments three times daily, and the EMR later included an order permitting the resident to self-administer nebulizer treatments after staff setup, but there was no evidence that an IDT self-administration assessment had been completed first. The record also lacked documentation showing the resident’s competency and safety to self-administer the nebulizer medication and treatment, including the ability to understand the medication purpose, follow directions, safely operate the equipment, recognize side effects or adverse reactions, and ensure safe administration and storage. During observation, the resident had nebulizer equipment and medication available in the room. The resident stated staff set up the medication cup and left while the treatment ran, then returned to ensure the machine was turned off; staff cleaned the nebulizer mask afterward. An LPN and RN confirmed the treatment was set up by staff, and the RN and DON stated a self-administration assessment should have been completed before the resident was permitted to self-administer medications.
Failure to Assess and Monitor Antipsychotic Use
Penalty
Summary
The facility failed to ensure that a resident receiving psychotropic medications was adequately assessed and monitored. R3’s admission MDS identified severe cognitive impairment and the need for assistance with ADLs, with diagnoses including non-traumatic brain dysfunction, unspecified dementia without behavioral, psychological, mood, or anxiety disturbances, non-Alzheimer’s dementia, anxiety disorder, and mood affective disorder. The resident’s physician orders included Risperidone 0.25 mg, two tablets by mouth every four hours PRN for agitation and paranoia, with a maximum of three PRN doses in 24 hours, and Risperidone 0.5 mg, one tablet by mouth three times daily for paranoia/agitation. R3’s EMR did not show that an AIMS assessment was completed upon admission despite the resident receiving antipsychotic medication, and the assessment was only completed after surveyor request. The record also lacked evidence that target behavior monitoring had been initiated for the antipsychotic use, with no measurable target behaviors documented, including frequency, duration, severity, precipitating factors, or response to interventions for agitation and paranoia. Interviews with the RN case manager and DON confirmed that AIMS assessment and behavior monitoring should have been completed upon admission or initiation of antipsychotic medications, and both acknowledged that target behavior monitoring had not been initiated.
Incomplete Care Plans for Anticoagulant Therapy and Cardiac-Related Needs
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents with significant medical conditions and medication-related needs. One resident had intact cognition and diagnoses including atrial fibrillation, heart failure, BPH, stroke, malnutrition, anxiety disorder, depression, and a cardiac pacemaker, and was receiving Eliquis. The resident also had a physician order for a condom catheter at bedtime and removal when getting up for the day. The comprehensive care plan printed 5/20/26 did not identify interventions or monitoring related to anticoagulant use, including bleeding risk, adverse effect monitoring, or staff awareness of anticoagulant precautions, and it also lacked interventions related to the resident’s cardiac conditions, pacemaker, and condom catheter use, including skin integrity monitoring and resident-specific catheter care preferences. A second resident with severe cognitive impairment and diagnoses including non-traumatic brain dysfunction, unspecified dementia, non-Alzheimer’s dementia, anxiety disorder, and mood affective disorder was also receiving Eliquis. The resident’s comprehensive care plan printed 5/19/26 did not include anticoagulant therapy, bleeding risk precautions, monitoring for adverse effects, or other interventions related to anticoagulant medication use. During interviews, the RN case manager and DON confirmed that anticoagulant therapy, the condom catheter, cardiac conditions, and pacemaker presence should have been addressed on the care plans and acknowledged that these items were not included.
Failure to Provide Scheduled Bathing and Grooming Assistance
Penalty
Summary
The facility failed to ensure that two residents who required assistance with activities of daily living received routine bathing and grooming services needed to maintain personal hygiene and dignity. R2’s MDS identified intact cognition and a need for ADL assistance, and the care plan directed staff to assist with dressing, grooming, bathing, and oral care while honoring personal hygiene preferences. R21’s MDS also identified intact cognition and a need for ADL assistance, and the care plan directed staff to assist with dressing, grooming, bathing, and oral care. R2’s bathing record showed a weekly bathing schedule, but the documentation did not show bathing was completed every week as scheduled. Baths were documented on several dates, but the time between some baths exceeded one week, and the record did not show additional refusals or reasons why scheduled baths were missed. During observation, R2’s hair was messy and greasy, and long white chin hairs were present. R2 stated she did not get baths very often because the facility was short staffed and said she did not have access to tweezers, a shaver, or a mirror. The EMR did not document that grooming assistance had been offered or provided for facial hair care. R21’s bathing record also showed a weekly bathing schedule, but the documentation did not show bathing was completed every week as scheduled. The record showed one refusal and several baths, but some intervals between baths exceeded one week, and there was no documentation of additional refusals or reasons for missed baths. R21 stated she had been in the facility since mid-April and had yet to have a bath or shower, and said staff were waiting for physician approval because of wounds, though that had been a while. R21 also stated she had only had her hair washed once with a shampoo shower cap while in bed. Staff interviews confirmed residents were expected to receive at least one bath weekly unless they refused, refusals should be documented, and facial hair should be addressed when noticed.
Missing Orders and Documentation for Condom Catheter Drainage Bag Care
Penalty
Summary
The facility failed to ensure appropriate care and services were provided for management of a resident’s external urinary catheter system. The resident had intact cognition and required assistance with ADLs, and diagnoses included atrial fibrillation, heart failure, BPH, stroke, malnutrition, anxiety disorder, and depression. Physician orders dated 4/29/26 indicated use of a condom catheter at bedtime, but the electronic medical record did not contain physician orders or documented instructions for cleaning, disinfecting, monitoring, or routinely changing the associated catheter drainage bag. During observation on 5/19/26 at 11:57 a.m., the resident’s catheter drainage bag was seen hanging on the side rail in the bathroom. Record review and observation did not identify documentation that the drainage bag was routinely cleaned, disinfected, monitored, or replaced according to accepted standards of practice. An LPN confirmed there were no physician orders addressing when the drainage bag should be changed or instructions for cleaning or disinfecting it. An RN case manager stated the drainage bag should have been changed weekly, but no orders related to changing, cleaning, or disinfecting were present. The DON stated the facility expected clear physician orders and nursing instructions for catheter care, cleaning, monitoring, and replacement schedules, and confirmed the facility could not provide evidence that such orders or guidance were in place for the resident’s condom catheter drainage bag care.
Failure to Preserve Dignity by Placing a Brief on a Continent Resident
Penalty
Summary
The facility failed to provide services in a dignified manner for 1 resident who was cognitively intact and had diagnoses including renal insufficiency, DM, and hypertension. The resident’s MDS identified him as continent of bowel and bladder and needing staff assistance with ADLs including bed mobility, transfers, and toileting. A bowel and bladder assessment also identified the resident as continent, and the care plan stated he was aware of the need to void or defecate and would request to use the toilet as needed. During interview, the resident stated staff put diapers on him even though he was not incontinent and said it made him feel like a baby. During observation, a NA placed a brief on the resident, and the resident showed the surveyor the brief and stated it had just been put on him a few minutes earlier. The NA verified she placed a brief on the resident that morning even though he was not incontinent and said she was unsure why she did so. RN-A confirmed the resident was continent and stated staff put a brief on him out of habit. The DON stated staff should not place a brief on residents who are continent and that it was important to maintain the resident’s dignity.
Failure to Provide Restorative Ambulation and Address Decline in Mobility
Penalty
Summary
The facility failed to provide restorative ambulation services and failed to respond to a decline in ambulation status for one resident who had mild cognitive impairment, dementia, hypertension, diabetes, weakness, and chronic pain. The resident’s care plan and restorative documentation directed daily ambulation with a front wheeled walker and staff assistance of one, and the resident was also identified as having limited physical mobility and being at risk for falls due to weakness, chronic pain, and an unsteadied gait and balance. However, the nursing rehab point-of-care record repeatedly documented ambulation as “not applicable,” with only one entry showing the resident ambulated for 15 minutes and one entry showing refusal. The resident stated she could no longer walk and that staff needed to help her get into bed and her wheelchair. Staff interviews confirmed the ambulation task was not being completed. A nursing assistant stated aides were responsible for ambulation but were not completing it, and another nursing assistant stated ambulation was supposed to be done but was not done very often; that staff documented it as not applicable when it did not get done; and that the resident had not walked at all for several weeks and was using a sit-to-stand lift with assist of two for all transfers. An RN stated the task just did not get done and that no plan had been created to fix it. The DON stated the resident’s condition had changed and a therapy evaluation should have been requested, and also stated the care plan needed revision because the resident would not be transferred with an assist of one. The resident’s medical record lacked an assessment for ADL decline, including any revision to the ambulation care plan.
Failure to Complete and Document Restorative ROM and Splinting
Penalty
Summary
The facility failed to ensure range of motion (ROM) was completed in accordance with therapy recommendations to maintain mobility for one resident with mild cognitive impairment who was dependent on staff for all care areas and had diagnoses including diabetes, hemiplegia, and hemiparesis. The resident’s care plan identified limited physical mobility, fall risk, weakness, contractures, and limited ROM, and included restorative nursing interventions for bilateral lower extremity passive ROM to active ROM, passive hamstring and heel cord stretches, PROM to both hands, and splint use for the hands. The resident’s restorative documentation from 4/20/26 through 5/19/26 showed the hand splints were worn 41 times and marked not applicable 20 times out of 90 opportunities, but the documentation did not identify refusals to wear the splints. The leg stretches were completed 3 times out of 30 opportunities, and the documentation did not identify why the stretches were not performed or whether they were refused. The resident’s untitled nurse aide care sheet also identified a restorative program and encouragement to participate in the Well Fit program. During interviews, a nursing assistant stated staff were supposed to encourage participation in the Well Fit program and complete PROM and AROM, but it did not get done very often and was often documented as not applicable because it was not offered. An RN stated nursing assistants were responsible for restorative programs but they did not get done, and no plan had been created to fix the issue. The DON stated staff should have offered the tasks and documented refusals, but believed staff may have stopped offering after repeated refusals; the DON also stated the restorative program needed to be updated and that staff were documenting tasks as not applicable, which she was unaware of.
Dirty can opener and contaminated dry storage bins
Penalty
Summary
The facility failed to keep 1 of 1 commercial can opener clean and sanitary and failed to store dry goods removed from original packaging in a manner that reduced the risk of cross-contamination. During an initial tour with the Director of Culinary Services (DCS), four white plastic bins in the food preparation area were observed on the floor and labeled for flour, white sugar, rice, and powdered sugar. The flour bin was about one-third full and had a black scoop partially covered with flour, including the handle. The bin labeled white sugar had yellowish-tan dry matter on the right lateral wall, and the front wall had red dry matter measuring 6-7 cm in diameter. The rims around the lids of all four bins were dirty with dark dust-like particles, and the DCS verified these findings and stated the scoop should not be left inside the bins and needed to be clean inside and out. The attached [NAME] brand can opener was also observed with its blade halfway covered with dry, red-colored matter. On a later kitchen tour, the can opener blade still had dry red matter, which had been pushed upward by 0.2 cm, and a small light amber particle was noted below it. The cook stated he had used the can opener that morning to open a can of cream of corn used for lunch. The DCS verified the dry matter on the can opener and stated it should be washed every time it was used to prevent cross contamination. Facility policy stated dry storage areas would be maintained to keep food safe and free of infestation or contamination, and the sample cleaning schedule stated can openers should be clean after each use.
Dignified Medication Administration Not Maintained
Penalty
Summary
The facility failed to provide a dignified experience for 1 of 2 residents, R20, during medication administration. R20’s records showed severely impaired cognition, inattention, disorganized thinking, verbal behaviors toward others, and diagnoses including severe dementia with psychotic disturbance, visual hallucinations, generalized anxiety disorder, PTSD, and delusional disorder. Her care plan identified mood, behavior, and sleep alterations related to Alzheimer’s disease, dementia, generalized anxiety disorder, paranoia, public outbursts, and accusations that people were throwing medications down her throat, and it directed staff to redirect and reapproach when she was resistive or combative, use a calm approach, provide reassurance, and offer comfort items. During observation, RN-A brought medications to R20 in the dining room and attempted to pour them from a small plastic cup into her mouth. When R20 removed one medication, Divalproex, and threw it on the floor, RN-A attempted again to pour the remaining medications into her mouth while R20 moved her head back and forth and tried to pull away. RN-A then raised her voice, stated the resident’s name, told her she needed to take her medications, pulled her chair back from the table, picked up the Divalproex from the floor, placed it in a separate cup, and asked why she would not take her medications. R20 responded that it was because the nurse was not being nice. RN-A then left with the remaining refused medications and stated R20 would take them later and that she always had a behavior when taking her morning medications.
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